Collaborative Agreements

[pharm B]

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So I'm taking a patient assessment course right now where we take H&P's and get really hands-on with the patient. I know you can set up a collaborative practice agreement in certain fields (coumadin clinics, diabetes management, etc).

My question is this: what stops a doc from having a pharmacist in his office, doing physicals, writing scripts (or more likely managing scripts on existing patients), etc? Is there a limitation on what pharmacists can prescribe for in collab-pracs? I assume this is based on your state, but if anyone has an overarching answer, it'd be appreciated. I assume we don't see this kind of set up because the pharmacist can't bill for doing a physical or similar services. Is that right?

Could this scenario happen:

Private practice general medicine office run by an MD/DO with a pharmacist in house to assess patients and manage prescriptions on all current patients (not new ones).

 

[spacecowgirl]

Depends on your state laws.

 

[pharm B]

if the law allows, will insurances accept billing for a pharmacist doing an H&P? I haven't figured out the business side of this yet, and I'm curious as to whether it's worth even considering. I figured I could post here or call each individual insurance company.

 

[R2pharmD2]

So I'm taking a patient assessment course right now where we take H&P's and get really hands-on with the patient. I know you can set up a collaborative practice agreement in certain fields (coumadin clinics, diabetes management, etc).

My question is this: what stops a doc from having a pharmacist in his office, doing physicals, writing scripts (or more likely managing scripts on existing patients), etc? Is there a limitation on what pharmacists can prescribe for in collab-pracs? I assume this is based on your state, but if anyone has an overarching answer, it'd be appreciated. I assume we don't see this kind of set up because the pharmacist can't bill for doing a physical or similar services. Is that right?

Could this scenario happen:

Private practice general medicine office run by an MD/DO with a pharmacist in house to assess patients and manage prescriptions on all current patients (not new ones).

I'm going to show my PY1 ignorance here, but does your typical PharmD have the proper training to conduct an adequate physical assessment? Would you need additional training to function in this type of role at the same level as a PA/NP?

 

[PumpkinSmasher]

So I'm taking a patient assessment course right now where we take H&P's and get really hands-on with the patient. I know you can set up a collaborative practice agreement in certain fields (coumadin clinics, diabetes management, etc).

My question is this: what stops a doc from having a pharmacist in his office, doing physicals, writing scripts (or more likely managing scripts on existing patients), etc? Is there a limitation on what pharmacists can prescribe for in collab-pracs? I assume this is based on your state, but if anyone has an overarching answer, it'd be appreciated. I assume we don't see this kind of set up because the pharmacist can't bill for doing a physical or similar services. Is that right?

Could this scenario happen:

Private practice general medicine office run by an MD/DO with a pharmacist in house to assess patients and manage prescriptions on all current patients (not new ones).

Easier to hire PAs. They have full prescribing privileges and they are cheaper. PAs can bill for everything. Easier all around for the Medical practice and they do not have to deal with any Collaborative practice agreement.

 

[pharm B]

I'm going to show my PY1 ignorance here, but does your typical PharmD have the proper training to conduct an adequate physical assessment? Would you need additional training to function in this type of role at the same level as a PA/NP?

Our patient assessment class can get pretty thorough, and with the right additional training, I could see you being good enough for this. If you spent a summer with a doc (as a student) assisting in this role and MTM on the patient, I think that'd be good prep.

Easier to hire PAs. They have full prescribing privileges and they are cheaper. PAs can bill for everything. Easier all around for the Medical practice and they do not have to deal with any Collaborative practice agreement.

I agree 100%. I'm still just trying to see if a pharmacist could actually function in this capacity. We're in school longer than PA's (for the most part) and get exposed to some of the same things, though not to the same extent. As a hypothetical, let's assume the pharmacist in this scenario was previously a nurse, below NP or PA level.

 

[owlegrad]

I'm going to show my PY1 ignorance here, but does your typical PharmD have the proper training to conduct an adequate physical assessment? Would you need additional training to function in this type of role at the same level as a PA/NP?

Varies wildly between schools. Most would require additional training, I would think.

 

[All4MyDaughter]

I have known a pharmacist or two who worked in a physician office. One managed warfarin and diabetes patients. That would be a good gig, if you could get it. I think MD's typically use nurses in that capacity b/c they are cheaper. Then there is an oncology group here locally that has it's own pharmacy and infusion suite and hires pharmacists to run to the pharmacy, supervise the mixing of chemo, etc.

 

[spacecowgirl]

if the law allows, will insurances accept billing for a pharmacist doing an H&P? I haven't figured out the business side of this yet, and I'm curious as to whether it's worth even considering. I figured I could post here or call each individual insurance company.

Doubt it. Lots of payers barely even pay for MTM codes. You can bill incident-to, but if the patient is seeing the doc the same day, or any other higher reimbursed service is being billed that day, you won't get paid. Insurers require credentialing for billing most codes; not sure how/if you could be credentialed for billing for what you're describing.

 

[R2pharmD2]

Our patient assessment class can get pretty thorough, and with the right additional training, I could see you being good enough for this. If you spent a summer with a doc (as a student) assisting in this role and MTM on the patient, I think that'd be good prep.

Varies wildly between schools. Most would require additional training, I would think.

That's pretty much what I suspected. Besides the billing difficulties, which sound fairly substantial, you'd need to train a PharmD to do something a NP/PA can already do, and do it for less money. Sounds like it wouldn't really make sense in most cases.

 

[pharm B]

That's pretty much what I suspected. Besides the billing difficulties, which sound fairly substantial, you'd need to train a PharmD to do something a NP/PA can already do, and do it for less money. Sounds like it wouldn't really make sense in most cases.

That's why I'm curious. We talk about MTM, and this seems like a good place to do it (assigned to a private practice's patient base), but it doesn't sound like a realistic opportunity.

 

[R2pharmD2]

That's why I'm curious. We talk about MTM, and this seems like a good place to do it (assigned to a private practice's patient base), but it doesn't sound like a realistic opportunity.

Yeah, I've wondered about it myself. There are pharmacists out there who make this kind of thing work, but it seems like they're so few and far between that it can't be realistic. My school offers a dual PharmD/PA program that would open things up for me if wanted to pursue something like this, but it seems like if I wanted to go that route I'd end up essentially doing PA work for PA pay. If I wanted to do that, I would have just went to PA school and saved myself the trouble

 

[rxlea]

look into the pharmacy practitioner training based on the ihs in arizona. our state is diligently working on it. pharmacists in rural areas here regularly do patient assessment as you describe and now will be able to do so more freely based on a law that was e'er passed I will post a more coherent response later

 

[pharm B]

ASHP has an issue statement regarding this, to a degree:

http://www.ashp.org/DocLibrary/Advocacy/Provider-Status.aspx

ASHP urges Congress to:
Remove barriers to patient access to pharmacists' medication related services by including them as non-physician providers under Section 1861 of the Social Security Act.

I don't know how much, if any, discussion is taking place regarding this.

 

[Farmercyst]

ASHP has an issue statement regarding this, to a degree:

http://www.ashp.org/DocLibrary/Advocacy/Provider-Status.aspx



I don't know how much, if any, discussion is taking place regarding this.

We didn't do H&Ps, but we did the medication management of asthma, diabetes, HTN, and coumadin at the medical homes for indigent patient populations in LA while at USC. They operate about 5 or 6 clinics, including one on skid row. All existing pts. We'd do BP, glucose and/or peak flow, and SOAP the encounter, manage meds/doses as needed. Not sure how reimbursement was handled though. That's the tricky part. It was arranged between LA County or QueensCare, depending on which clinic you were in.

 

[Pharmizzle]

New Mexico allows for a Pharmacist Clinician license to practice sort of what you're describing, although from what I understand, there are still the issues with reimbursement that have already been discussed. Here's some basic info if you're curious though:

http://www.nm-pharmacy.com/Pharmacist_Prescribing/Pharmacist_Clinician/pharmacist_clinician.htm

Based on what I've heard, the best place to practice this sort of thing is with IHS; it seems like pharmacists get a lot of autonomy and a wide scope of practice.

 

[pharm B]

Is ASHP acting on the above mission statement? Seems like something we could push for, but I also know it's just as likely to be a fluff statement with no wind in the sails.

 

[joetrisman]

Is ASHP acting on the above mission statement? Seems like something we could push for, but I also know it's just as likely to be a fluff statement with no wind in the sails.

I doubt it. I'm starting to feel the same way about the ASHP as I do about APHA. In the new AJHP, they have not one but TWO articles talking about the benefits of expanding technician roles in the pharmacy - one being tech-check-tech (its a hoot...actually mentions a tech might be able to better check than a rph). Thanks for advertising more "we really don't need pharmacists as much any more" info AJHP 🙄